Are Aware Your Accident Benefits Were Reduced in 2011?

‘Generous’ accident benefits?

Alan Shanoff

October 29, 2011

 

In attempting to justify Ontario’s high and increasing car insurance premiums, the Insurance Bureau of Canada has trumpeted what it calls Ontario’s “generous” no fault accident benefits.
We’re told our benefits, even with last year’s drastic reductions, continue to be “the most generous accident benefits coverage in Canada.”

Is that so? Consider that the vast majority of claims fall under what are called the minor injury guidelines.

Consider that the entitlement to medical and rehabilitation services for minor injuries is capped at $3,500.

Consider that the $3,500 includes the cost of assessments, examinations and reports. Does that sound very generous?

A minor injury includes any one or more of such things as sprains, strains, whiplash associate disorder, contusions, abrasions, lacerations, partial joint dislocation and any medical condition that occurs as a consequence of these injuries.

Now consider how quickly your $3,500 can be eaten up with an assessment, an examination or report, followed by physiotherapy two or three times a week.

Now tell me how generous our accident benefits are.

Throw in some sessions to deal with a psychological injury and see how far the $3,500 takes you.

Rather than being the most generous, Ontario has the lowest minor injury benefits in the country.

To be sure, if the injury goes beyond the definition of “minor,” or if there’s “compelling evidence” a pre-existing condition will prevent “maximal recovery,” then the accident benefit increases to $50,000.

So, surely that’s the most generous in the country?
Nope. Sorry. It isn’t. Worse, guess who gets to make the determination of whether an injury qualifies as minor or non-minor, or whether there’s compelling evidence.

It’s your doctor, right?

Nope, it’s the insurance company’s appointed adjuster.

Wait a minute, you ask, when did adjusters get their medical licences?
Believe it or not, car insurance adjusters have the power to categorize an injury as being minor or non-minor.

They have the power to disagree with the injured person’s own doctor and override the diagnosis and prognosis of medical professionals, without even having to seek out a supporting medical opinion to justify the denial.

According to psychologist Andrew Shaul — he’s treated accident victims for about 15 years — some adjusters will seek out a second opinion, but these second opinions are rife with financial conflicts of interest.

Any expert retained to provide a second opinion knows that if he doesn’t support the adjuster, he’ll likely lose the adjuster’s business.

If you don’t like what the adjuster or his expert has decreed, you can seek mediation and arbitration via the Financial Services Commission of Ontario, an agency of the Ministry of Finance that regulates insurance companies in Ontario.

The catch is you may have to undergo waiting periods of two to three years before you receive a decision.

Dr. Shaul has seen marriage break-ups, homes having to be sold and accident victims resorting to drug or alcohol abuse following mistreatment by insurance companies and their adjusters.

He says in many cases, accident victims suffer more trauma after an accident, due to the actions of the insurance companies, adjusters and their examiners, as opposed to the accident itself.

Dr. Shaul concedes insurers must deal with fraudulent billing practices but believes that pales in comparison to the problems caused by insurers’ improper denial of insured services.

Properly interpreted and administered, the minor injury guidelines make sense, although I don’t understand the justification for the artificially low limit of $3,500.

Moreover, we can’t leave the job of making medical determinations to adjusters, or even their financially conflicted “experts.”